Monday, December 28, 2009

When Cardiologists Sue

It's sad that cardiologists have had to sue as their last resort to save their practices:

"Heart specialists on Monday filed suit against Secretary of Health and Human Services Kathleen Sebelius in an effort to stave off steep Medicare fee cuts for routine office-based procedures such as nuclear stress tests and echocardiograms.

The lawsuit, filed in U.S. District Court for the Southern District of Florida, charges that the government's planned cutbacks will deal a major blow to medical care in the USA, forcing thousands of cardiologists to shutter their offices, sell diagnostic equipment and work for hospitals, which charge more for the same procedures.

Perhaps other professional organizations will be forthcoming with similar suits as private doctors and their patients pay dearly for the reform efforts underway. Meanwhile hospitals continue to build. Pharmaceutical and medical device companies stocks rise. But did we really think the government's promise to find nearly $500 billion in "wasteful spending" from Medicare and Medicaid to resolve the fiscal realities of the ridiculously expensive legislative reform efforts could happen any other way?

No doubt the suit will bring this issue to the forefront for patients. It will be interesting to see how this plays out. Perhaps a compromise. Perhaps a further delay.

But make no mistake. specialists are first in the sights of the health care reformers. They and their technology are the bad guys. They are expensive. Innovation is evil. And while the American College of Cardiology may have significant resources to fight this fight and have a legitimate gripe, the government's legal purse is infinite. Eventually, the ACC's finances will be worn thin.

And so all the great reform efforts underway, America will have "primary care" for most of its citizens lucky enough to find a primary care doctor and specialist care only for those living close enough to a hospital to receive it.

16 comments:

Keith
said...

Wes,

Innovation is not evil. It is only evil when it inexorably results in hihger and higher costs. Most bisinesses inovate to create better and often cheaper products. We create better products (most of the time), but then they always cost twice as much as the old product. That is why technology is in the sights of the people who are trying to reign in costs.

I agree that innovation is not evil, but in the current contect of health care reform, innovation is, by its very nature, expensive. Because it is expensive, it garners the appearance to reformers of being "evil." Innovative ideas are also difficult to demonstrate utility in formal comparative effectiveness research (CER) trials in part because it is very expensive to do so, and must have a large enough population base upon which to make it worth it to risk studying. The prohibitive fees required of the government from medical device companies will cause many ideas to never reach development or patients - hardly a innovation "friendly" environment.

Innovation can certainly be expensive, but a large part of the problem is that companies working on so called innovation are not constrained by cost. In the real world, companies can only innovate and create better products that people can afford. In the medical world, we see many products that offer minimal improvements over the prior treatments at exponentially increasing prices. Drugs like Avastin are a prime example of a treatment that can add 3-6 months of life for a cancer patient at a cost of 100 grand per year. There will be no innovation at all eventually, if the federal goverment and most peoples wages are consumed by this medical cost tsunami, so we must balance the pace of innovation with what we can afford. To suggest that there is an endless supply of resources that should be plowed into medical innovation seems like shortsighted public policy and that seems to be what is being advocated. There are too many other areas that require innovation (renewable resources of energy for example) to spend everything on medical innovation alone.

Much of the reason companies are not restrained by cost is because of the artificial prices set by the government. The prices on defibrillators have not changed because the government continues to pay high prices thanks to lobbying efforts by the device companies and hospitals who insist on the high prices to cover their expenses of development and implantation. In fact, it's their very pricing systems that have kept prices high.

But now they need to find an answer pay for their 115+ additional agencies created by this reform effort all the while promising to hold down costs.

I don't buy it.

And in the process, wer're killing access to critical care services for patients and commoditizing our profession.

Unfortunately cardiology must blame a few of its own for the financial impositions that will be imposed on many.As an internist (pejorative primary care physician ) I see daily the overuse of the diagnostic devices the use of which will be now compensated at a lower fee.Is a nuclear study needed yearly on a patient with stable coronary artery disease? and should an ECHO,carotid ultrasound and holter be thrown in for good measure?While the measures imposed will harm both cardiologists and possibly their patients' I am afraid that responsibility for this unfortunate state of affairs must be squarely shouldered by these professionals who believed it politically correct to fiddle as Rome burned

My cardiology friends all have high blood pressure over what awaits them. We in gastroenterology are reight behind you. I think it's worse than a zero sum game, where we specialists will simply be transferring our income to others. It may be that the physician compensation pie is shrinking over all. They'll throw a few percentage points to primary care -as if that will lure folks there - and slash at the specialists. Their preference? Salaried physicians across the country as exists in their beloved Mayo Clinic model.

The fact of the matter is that the American College of Cardiology seems to do little to counter this trend if indeed these items are overpriced. And of course today, the news is hitting about the paucity of evidence that demonstrate the benefits of stents and newer pacemakers, many with low numbers of patients and solitary studies with no follow up. Once again, it is foolhardy to expect the industries that profit from this technology to be honest and unbiased in the results they produce given the significant dollars at stake. This has all been contributed to by the Laizze Faire attitude of the prior party in power who felt that the heavy hand of goverment was constraining technological developement, and hostile towards anything that constrained buisiness as well as hostile to science in general has had a friendly attitude towards buisiness in general. Over that time, Guidant was fined three times for fraud and malfeasance in what it has reported to the goverment, and innumerable episodes of pharmaceutical companies hiding unfavorable data regarding their products have emerged.

Most of the profits go to items that represent no significant superiority over the prior treatment, but only extend the patent and high cost of a product or device. I understand that when the device industry spokesperson was asked how come there are no double blind studies of their products, they stated there is no way to implant a placebo pacemaker, but there is no reason that they cannot compare their old pacemaker with the new and improved (and often more expensive) one. They avoid doing this however for fear they cannot demonstrate better results.

Are not cardiologists the ones that actually must install these devices? Are you a powerless lot with no input to what devices get used and what their costs are? Or have too many cardiologists been bought off as shill salesman engaging in these poorly designed studies and then pushing their wares based on scant evidence onto their fellow cardiologists while collecting fees from the device makers for their efforts. You might see why I am skeptical after years of putting in billions of dollars of stents only to find they really do not offer any better outcomes than medical therapy. Can the goverment and insurers, as well as the patients have their money back for all these useless procedures (see my prior comments of why we need comparitive effectiveness research!)?

i hear a lot of people talking about unnecessary tests, but my experience has absolutely been that many are initiated because the primary doctor or non-cardiac specialist didn't have time or requisite experience to take a detailed history and examination. as to the question of echo and holter--i'd like to see some data as to how many of the ones that are not indicated came from internal internal cardiology referrals and how many came from physicians and NP/PAs not in cardiology.

As an IDTF and Medicare provider in Texas- the new fees for an Echocardigram will be disastrous for our Medicare patients, our employed techs and the cardiologist who depend on our service. An echo/ Doppler is an important diagnostic tool that is usually ordered by an attending cardiologist and it is performed by highly accredited registered technicians (ARDMS). It is performed with very expensive state of the art ultrasound equipment that easily costs in the 6 figures. Patients life's have been saved by this important study. The test takes around an hour to do properly, many measurements are taken along with views of the heart. Technical skill is involved. We have seen cases where the echo performed in a doctor's office has saved many life's. So CMS bundled this study in '09 using one diagnostic code, and cut its cost in half. That was a shock but now Medicare is cutting this test again by 40%! It's absurd!Cardiologists will be sending their patients to hospitals, and in the long run more money will be spent because preventive care for the elderly has gone out the window. Our government is not efficient, it is a bureaucracy that is mismanaged and broke and has no idea what good medicine and good preventive care accomplishes.

I am not a cardiologist, I am a critical care nurse. I have a few questions:

1. Isn't there a better way to curb the high use of expensive technologies, with, for example, an effective tort system, preventing cardiologists from feeling the legal system hanging over their heads ready and eager to say, "well, we have this technology available, why did you fail to use it?" Medicine is not black and white. Those who do not work within it believe there is always a clear and definitive answer to those who need certain tests, and those who do not - as though doctors can magically and without cost peer into the chest of a human being and visualize the need, or lack of need, for certain tests, or peer into their brains to know beforehand who actually needs an MRI, and who does not.

2. Even IF cardiologists hold responsibility for high spending on these studies (and, even if they do, tort reform would likely be a better solution), WHY the callousness over the true victims - the patients? Some people may feel a sense of vindication slapping the hands of cardiologists, reducing their incomes and closing their clinics. But they are not the ones who REALLY suffer here, not in the short run or the long run - it's the patients who are failed by the system who will really pay.

Everyone posting seems to be stating a different side of the same argument. Our political class made promises to the public saying that we contribute payroll taxes and the government will pay for your medical care. With a third party payer, there was no motive for cost constraint. The consumer was separated from the provider. Rather than real health reform with our policitical class leveling with the population about the need for rationing we see a health care bill which forces the physicians to ration. Physicians are being coerced by the government with a take it or leave it sentiment. Blame the pharmaceuticals, device makers, insurance companies, etc. but until a free market system (catastrophic insurance with health savings accounts) is established health care will move exactly opposite from where those in power wish i.e. less access, less quality.

I find it perplexing that you, as an internist who has the luxury of referring the risks along to the specialists, could deem it appropriate to point your finger at those very specialists for overuse of diagnostic technologies. I think it must be easy to point your finger at specialists for doing too many investigative studies, when the risks for not doing them do not fall onto your lap. Possessing the luxury of passing the risks and then blaming those you are able to pass it along to for overuse of technology seems disingenuous to me.

When medicine becomes 100% crystal clear and ALL cardiologists - or specialists for that matter - definitively know and agree with 100% certainty what advanced technology tools to use and when, because ALL diseases present 100% the same with ALL patients - THEN we can blame them for overuse of technology when they test beyond the scope of a specific symptom set. But that will never, ever be the case.

I have an HSA, which makes me think more carefully about recommended medical care for my family, and what it costs. Is it surprising that someone would spend his own money a little more carefully than someone else's?

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About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.